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Home My WebLink AboutCOLONIAL PARK BLK 2 LT 9Onsite File Colonial Park Block 2 Lot 9 #050-302-09 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211332 PID Number: 050-302-09 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name JAMES & SANDRA JOBKAR ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 19639 SECOND STREET, EAGLE RIVER ❑ Other Phone7Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot COLONIAL PARK 2 9 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station St Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft' Ft. Well 100'+ __ 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ -- NA Foundation 10'+ __ LIFT STATION Manufacturer Capacity Gal. Remarks Alarm location Electrical installed by Installer DENALI EXCAVATION PIPE MATERIAL House to tank 3034 Tank dra of e o 3034 Drainfield CO/MT 3034. Inspector FWCS BENCH MARK (Assumed elevation) 100 ft Inspectio Vt 8/25/2021 8/25/2021 Location and description 2nd : 3rd 4'h TOP OF MAN HOLE ON-SITE WATER AND WASTEWATER SECTION APPROVAL Conditional Approval: Date .� " " ...... Curtis Huffman Septic System Y Approved - CE 128991 •`4�� Date !y 202j C ��'�'1�•.•8/26/2021.•�C� FD t�P�'-„' Note: this approval does not include well permit requirements. �'pROFES510O kRt:v UJ/VG/ 10) RIGHT OF WAY PERMIT R212174 Type:Encrchmnt Status:Issued Grid:NW0055 Date Applied:09/03/2021 Date Issued:09/03/2021 Issued By:claudia.pinard Construction Start Date: Last Updated:09/03/2021 Last Updated By: claudia.pinard Permittee:JOBKAR JAMES J & SANDRA L Work Order:Utility: Contact Person:James Jobkar (907) 229-5602 Primary Inspector: Jon Sauerbrey Address/Loc:19639 SECOND ST, Eagle River - @ Hillcrest Lane. Legal Description:COLONIAL PARK BLK 2 LT 9 G:0055 Original Work Description:Monitor tube encroaches 4.0 feet into the 20.0 foot Utility Easement. POST IN A CONSPICUOUS PLACE ALL WORK MUST BE INSPECTED Field Inspection Request required 2 working days in advance of starting work and 2 working days in advance for final inspeciton. Call (907) 343-8206 (voice recorder) for scheduling. Permit is not valid without the call-in and also must include the one-call ticket (utility locate) number. MUNICIPALITY OF ANCHORAGE - RIGHT OF WAY DIVISION 4700 ELMORE ROAD TELEPHONE (907) 343-8240 EMAIL: moarowrequests@muni.org Fee Description Quantity Amount Permit 1 $120.00 Total Fees:$120.00 Summarized Financial Transactions See reverse for requirements/remarks. I have read and understand both sides of this permit. I agree to the terms and conditions; and I certify that all work will comply with federal, state, and municipal codes and regulations and the provisions of this permit. Signature:Date: DocuSign Envelope ID: A04784F5-BF8C-4695-A6ED-02024A5D9804 9/14/2021 Construction Requirements and Notes: 1. This permit has been issued based on the assumption that the information contained in the pals and supporting documentation is correct. Any and all omissions are the responsibility of the permitee. Any change in the scope of work requires a revised or new permit and Traffic Control Plan (TCP). 2. Contractors’ acceptance of this permit constitutes acceptance of the Municipality’s bonding requirements, and is contractor’ representation that contractor has and will comply with those requirements. Unless a specific bond is applied to this permit by written reference, the contractor’s performance bond on file with Development Services, Right of Way Enforcement, shall suffice as the required bond. 3. The Permittee shall post a copy of the permit in a conspicuous location at the place to which the permit pertains before any work there is started and shall remove the permit only after the Right of Way Inspector has accepted the work as being in compliance with the permit. 4. The Municipality has the right to inspect and/or reject materials and workmanship not to Municipal standards, to stop work until corrections are made, or to require removal of the facility and to charge time, material and equipment to the Permitee to correct the facility if they fail to comply with the conditions of the permit. 5. Permitee is responsible for locating and protecting all utilities and survey markers in the work vicinity. For utility locates, call Alaska Digline at “811” or (907) 278-3121. 6. The contractor shall erect signs, barricades and detours in accordance with the U.S. Department of Transportation “Manual on Uniform Traffic Control Devices”, Part VI – Traffic Controls for Street and Highway Construction, Maintenance, Utility and Emergency Operations. Failure to do so may result in fines being assessed under Title 14 for work not in conformance with a permit. 7. Changes in the approved road closures or scope of work resulting from emergency circumstances may be allowed during construction. It shall be the responsibility of the contractor to notify the Permit Office, 343-8206, and/or obtain an approved Traffic Control Plan (TCP). It shall be the contractor’s responsibility to notify the following agencies: Fire Dispatch 267-4950, Police Dispatch 786-8900, Alaska State Troopers Dispatch 269-5511, People Mover 343-8253 and School Bus 742-1207 or 742-1209. 8. All construction shall be in accordance with the current edition Municipality of Anchorage Standard Specifications (MASS), applicable municipal codes and regulations and the approved drawings and special provisions of this permit. 9. As a condition of this permit all excavations will conform to the standards outlined in OSHA 29CFR, 1926 Subpart P. 10. The Right of Way shall be restored to the same, or better condition, than it was prior to the contractors’ work being performed. The work shall be performed diligently and continuously, until completed to the satisfaction of the Municipal Right of Way Inspector. 11. All underground installations within a public place shall be buried at a minimum depth of forty-two inches (42”) below the final surface elevation, i.e. bottom of drainage ditches, road shoulder or finished grade. 12. Permanent paving, recycled asphalt pavement (RAP), chip seal, sidewalks and curb and gutter must be replaced within 7 working days after underground work is completed. 13. Winter Condition Requirements (applicable to all Right of Way Permits). a. No trenching and or excavation is allowed within the road prism except for emergency repair of existing utility facilities or by approval of the Director of Development Services. b. Crossing of the road prism shall be by boring technology. c. No frozen material shall be placed in the excavation as fill and/or backfill. A source of non-frozen fill and/or back fill material shall be available. d. All frozen ground within the Right of Way shall be thawed prior to excavation. DocuSign Envelope ID: A04784F5-BF8C-4695-A6ED-02024A5D9804 MUNICIPALITY OF ANCHORAGE Development Services Department Right of Way Section ENCROACHMENT PERMIT R212174 THIS AGREEMENT, made this 3rd day of September, 2021, by and between JAMES J. JOBKAR & SANDRA L. JOBKAR and their heirs, administrators, and assigns, hereinafter called “PERMITTEE”, and the Municipality of Anchorage, a municipal corporation organized and existing under its Charter and the laws of the State of Alaska, hereinafter called the “PERMITTER”. WITNESSETH: WHEREAS, PERMITTEE is the owner of the following described real property: COLONIAL PARK, BLOCK 2, LOT 9, according to the official records thereof, on file in the office of the District Recorder, Anchorage Recording District, Alaska, and; WHEREAS, PERMITTER owns and/or maintains the real property more particularly described as follows: The TWENTY FOOT UTILITY EASEMENT, immediately on the north side of PERMITTEES property as shown on Plat No. P-688, on file in the office of the District Recorder, Anchorage Recording District, Alaska, and; WHEREAS, PERMITTEE has placed a monitor tube upon the referenced real property which encroaches 4.0 feet upon the PERMITTER’S 20.0-foot Utility Easement. NOW, THEREFORE, it is mutually agreed between the parties hereto that: 1. The PERMITTER, acting through the Director of Development Services Department, hereby grants to the PERMITTEE the privilege of allowing monitor tube to encroach 4.0 feet upon the PERMITTER’S 20.0-foot Utility Easement, as shown on “Attachment A,” included herewith. 2. The PERMITTEE agrees forever to indemnify, defend, save and hold harmless, the Municipality, its officers and employees, from any and all lawsuits, claims or actions brought to any person for or on account of damage to property or injury, disease, illness or death of persons, including all costs and expenses incident thereto, arising wholly or in part from or in connection with the existence of, alterations, maintenance, repair, renewal, reconstruction, operation, use or removal of the encroaching monitor tube, as placed upon the PERMITTER’S 20.0-foot Utility Easement. 3. The PERMITTEE shall not assign or transfer any of the rights granted herein to another individual or company without first notifying and securing the ap proval of the Director of Development Services Department. DocuSign Envelope ID: A04784F5-BF8C-4695-A6ED-02024A5D9804 4. This Agreement and Permit grants PERMITTEE no interest in PERMITTER’S real property whatsoever, except only the encroachment rights described herein. 5. The PERMITTER reserves the right to revoke this permit upon twenty (20) days written notice to the PERMITTEE. The PERMITTEE agrees upon such notice of revocation, to move said encroachment(s) from the 20.0-foot Utility Easement in which it is placed. Should the PERMITTEE refuse or fail to comply with said written notice, the PERMITTER may, without further notice to the PERMITTEE, remove or cause to be removed the encroachment(s), and the PERMITTEE hereby agrees to reimburse the PERMITTER for all costs incidental to the removal thereof. In addition to the mutual promises heretofore made, the PERMITTEE has paid the PERMITTER a one-time permit application fee of $120.00. The PERMITTER hereby waives the annual fee of $315.00. IN WITNESS WHEREOF, the parties hereto have hereunto set their hands and seal the day and year first hereinabove written. GRANTEE: GRANTOR: MUNICIPALITY OF ANCHORAGE James J. Jobkar Jack L. Frost, Jr. Owner Right of Way Supervisor Sandra L. Jobkar Owner September 13, 2021 DocuSign Envelope ID: A04784F5-BF8C-4695-A6ED-02024A5D9804 9/14/2021 9/14/2021 MUNICIPALITY OF ANCHORAGE Gn-Slt$ VVatGr & Wastevwat,e r Program PO Bax 190850 4700 Elmore Road AnChoriga, Alaska 99519.6654 PhVW: (9QT1 r9G4 Pyr. 007) : x$97 hA tp: ff vmrw. rrru ni. �& n a a On- -Ite Wastewater Disposal System Pert -nit Perrnit Numbar_ DSP211332 Work Type, SeprioTank U pgrade Tax GodG Nurnbor: 46❑3D2051QU❑ Site Legal Address; COLONIAL PARK BLK 2 LT 9 =0455 Site Mailing Address: 19839 SECOND T. Eagle River Owner; J013KAR.IAMES J & SANDRA L Design Engineer: FIRST WATER CONSULTING Th is permit is for the Go ns tr uatioa of: Ei f-ectiue Dat -9= Expiration Date. Lot Size in Sq Ft: Total Bedrooms: isenr n n u j 5: r tpuVImL,int Bf17.2021 8f 17.202 2 3.5540 ❑ Disposal Field 0 Septic Tank ❑ H oldi ng Tani ❑ Prete ❑ PrIvate VVel I ❑ Water Storage AEI c on structlon shall bin in accords n ca with 1 . The attached approved design. 2. Al I Tee u irements specifies in Anchorage fel u n icipal aDde Chapters 15.55 and 15.65 and thG State of Alaska Yvas t vat,er Disposal Regulations (18AAC72.) and girl king VVater Rei ulaC on$ (1 WC00) 3_ The wastuwaler rode req ulrez In s pectlons d url n g thu Insial kion. The angIniner stlall nc tlfy the aevelopmem Servioos Doparlment per AMID 1x.65. Pro+rede no klfioatipn fey oalliN (907)143-7904 (24, 7)_ 4_ From Octobe r 15 to Ap ril 15, a subs urface sail a bsorption system under consitru otion d uring freezing weather s Rall be eilher: s_ Opened and Closed on the same day. or d. Coaerea, sealea, and heated ko prevent freeziriq E I R revision: I f if1 fin hl as -tart ift surrey. sr�Gmitted ka dose ou5 this permit, oon�firms that thebo1 loreI-n th a Utility Ea5 ement, a Ri-ght-of-Nay En croa�chrn eni Pe unit should Oe of�tai n (it wi II de ragkjirad prig ko ure COSA -approval). Received By Issued By: 61e: 8/1711 13ale: h F 3 MUNICIPALITY F ANCHORAGE Development Services Department ="' Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-302-09 Property owner(s) JAMES & SANDRA JOBKAR Day phone Mailina address 19639 2nd STREET, EAGLE RIVER, AK 99577 Site address 19639 2nd STREET, EAGLE RIVER, AK 99577 Legal description (Sub'd., Block & Lot) COLONIAL PARK 132, L9 Legal description (Township, Range & Section) Lot Size 35,640 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank Fx� Upgrade ElDuplex (D) El Holding Tank ❑ Renewal El Multiple Multiple Dwellings ❑ Privy El and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. gnature of property owner or autnorizea agent) Permit/Rush Fees: 225 Date of Payment: Receipt Number: —0011-3 13 ul Permit No. 0SP 2 I /33 2 Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com August 9, 2021 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: COLONIAL PARK BLOCK 2, LOT 9 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1000-gallon HDPE tank per the attached design to serve the existing 3-bedroom residence. The design is based on a hand-drawn, digitized as-built survey, which shows the existing tank within the 100 well radius. Well radii will be confirmed at construction and if it is determined that separations cannot be maintained for a gravity-fed system, a waiver will be requested with the inspection report. Granting of this waiver will be justified due to the improved HDPE tank material and the well is on the opposite side of the house with a surface run greater than 100. The lot and area are served by private wells. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211332, Rebecca Carroll, 08/17/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211332, Rebecca Carroll, 08/17/21 -.-- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS LOOATION NO. OF BEDROOMS ]Well 't Abs°rPt'°~es Dwelling , PERMIT NO. ~ DISTANCE ~O: I i 0 I'0 ~ h ~ Manufacturer ~ ~~, Material No. of compartments Liq. c~p~ ~ gallons IF HOMEMADE: Inside length Width Liquid deptE ~ DISTANCE TO: Well ~eTn: PERMIT NO. ~ ~ ~ Manufacturer v ~ /~ Material Liquid capacity in gallons Q Well ~ PERMIT NO. ~ ~S~A~C~ ~o: 1~ m ~oun~,o._ ~ ~+ ..~es~ ~o~.~ .+ ~ Z Length ofeac¢~ ,~ w,~ inches ' ~ No. of lines ~ line Total leng~o~i~ Trench ' Distance bet s ~ ~ ~ Top of tile to finish grade t Material beneath tile Total effective a srp ' n ~ ~ ~¢ inches Length Width Dep~ PERMIT NO. ~ ~ Tgpe of crib Crib diameter pth Total effective absorption area ~ Well Buildin~ foundation ~earest lot line ~ DISTANCE TO: ~ Class Depth Driller ] Distance to lot line PERMIT NO. ~ ~ ~ ~-T ~.~/ ~ DISTANCE TO: Building foun ~ ~ Sewer~ne / ~ ~ ~ Septic tank Absorption area(s) OTHER INSTALLER REMARKS -- 72-013 I ;v. 3/78) ................ PERMIT NO. MUN I C I PAL I TY OF Ar-ICH'--'RAGE DEPfiRTMENT ( HESLTH 8ND ENVIRONMENTSL ._JTECTION 825 ~L''~ STREET, RNCHORAGE, AK. 99501 2~4-4720 ON--SITE SEWER PERMIT 82084? ) APPLICANT LOCSTION LEGAL RAINBOW CONST LgB2 COLONIAL PK PO BOX 25i E.R. 995?7 LOT SIZE TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH ~94-3485 999999 SQUARE FEET MAXIMUM NUMBER OF BEDROOMS SOIL RATING THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM DEPTH= 12 LENGTH= 28 GRAVEL DEPTH= 8 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTSNCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). REQU I RED SEPT I C TANK S I ZE= 1000 GALLONS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPSRTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THST THE WELL WILL SERVE. TWO ( 2 ) INSPECT I O~S ARE REQU I RED BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION 8ND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR 8 PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICSTIONS AND CONSTRUCTION DIAGRAMS ARE RVAILABLE TO INSURE PROPER INSTSLLATION. PERM I T E>(P I RES DEC-EMBER I CERTIFY THAT l: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS 8ND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORSGE 2~ I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOl LS LOG [] PERCOLATION TEST PERFORMED FOR: J~J"~ J~J J~c~,,,.--..) /.-- (3 13 14 15 16 17 18 19 2O COMMENTS 1 SLOPE SITE PLAN WAS GROUND WATER ~ ~) S L ENCOUNTERED7 O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date TTirr~ Time Water Drop ) Robert A. PERCOLATION RATE (minutes/inch) Ne. t 4574i TEST RUN BETWEEN -- lET AND -- FT CERTIFIED B DATE PERFORMED BY: 72-008 (6/79) SULLIVAN WATER WELLSRE E!..Y-..E P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 OWNER OF LAND ADDRESS // LEGAL DESCRIPTION DATE - Started '7// PERMIT NUMBER ~, ,'~,~ <~- DEPTH OF WELL ~? a:' ! 7 ~--'~ STATIC LEVEL OF WATER FT. '~ ':r~ er ~ .~CL:,~ o ~, ~ ~' DRAW DOWN FT. / ,~ Ended ~' / GALS. PER HR ~ ~ ¢: ~" KIND OF CASING ~ ~ o ~/ KIND OF FORMATION: From Ft. to ~ Ft. From Ft. to From.~Ft. to Ft. From Ft. to ~?G Ft. From Ft. to ,~ 3 Ft. From Ft. to /~? ,Ft. From f Ft. to -%to Ft. From ~ · Ft. to<)Jf' Ft. From / /Ft. to /or Ft. From ,~ Ft. to ~,'~ Ft. From "' Ft. to dT~] ;~ Ft. From ~ Ft. to 2 ..'~ ~ Ft. From Ft. to Ft, From__.Ft. to Ft. From Ft. to.__.Ft From__Ft. to Ft. From Ft. to Ft, From__ From From From From Ft. to Ft. Ft. to__Ft Ft. to__Ft Ft. to__Ft, Ft. to FL Ft. to Ft. Ft. to__Ft. Ft. to__Ft. Ft. to Ft, .Ft. to Ft, Ft. to Ft Ft. to Ft Ft. to Ft Ft. to Ft. Ft. to Ft. __Ft. to Ft. Ft. to Ft MISCL. INFORMATION: DRILLER'S NAME PERMIT NO. DEPRRTMENT OF HERLTH RND ENVIRONMENTAL PROTECTION 825 'L.~ STREET.. HNCHORRGE, RK. DD501 264-4720 14ELL PERt-1 IT ( 8105~8 ) RPPLICRNT GREINER CONST P.O. BOX 25t., E.R. 694-3485 LOCRTION 2ND STREET., E.R. LEGRL L9 B2 COLON~RL PRRK., E.R. LOT '=IZE ~2~ '~],IIRRE FEET MINIMUM DISTRNCE BETWEEN R WELL RND 8N9 ON-SITE SEWRGE DISPOSRL S9STEM IS i00 FEET FOR R PRIVRTE WELL OR i50 TO 200 FEET FROM R PUBLIC: WELL DEPENDING UF'ON THE T9PE OF PUBLIC WELL. MINIMLIM DISTRNCE FROM 8 PRIVRTE ~ELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNIT9 SEWER LINE IS 75 FEET. WELL LOGS PRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRV RPPL'Y. SPECIFICRTIONS RND CONSTRUCTION [:,I8GRRMS PRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. PEF-:td ! T E;:-(F" Z E:ES E:,EC:EtdBER Z-:2L.. ~._gE:I I CERTIFY THRT t: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH 8'Y THE MUNICIPRLITV OF RNCHORRGE. 2' I WILL INSTRLL THE SVSTEM IN RCCORDRNCE WITH THE CODES. 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Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 7/1981 Total depth 332 ft Cased to 40+ ft (PER MOA DOCS) Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 5/31/2024 Static water level at beginning of test 294 ft. Well production at time of test 4.5 gpm Water storage tank volume NONE gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 1.98 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 5/31/2024 Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank 49” Date of pumping 5/30/24 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 8/20/1982 ALL standpipes present per record drawing Total measured depth from existing grade 12 ft (max) Measured depth to pipe invert from grade 4.8 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective. (ED) If not, state depth into effective 7.3’ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced 2000 gallons 5/30/24 date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 5/31/2024 Results Pass Fluid depth prior to test 2 in Water added 480 gal New fluid depth 11 in Elapsed time <20 min Final fluid depth 2 in Absorption rate 450 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 96 in (MOA 8’ ED) Effective depth used 10 in (Final fluid depth & missing ED) Effective depth (ED) remaining 86 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED per measured observations of sump invert / top of pipe perforations & appears 0.7’ or 8” of ED is missing. COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 6/27/2024 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 6/27/24 MUMCIPALITY OF ANCHORAGE 3 } �€tt Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section — Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-302-09 1. GENERAL INFORMATION Expiration Date: be C Complete legal description COLONIAL PARK BLOCK 2 LOT 9 Location (site address) 19639 SECOND STREET, EAGLE RIVER, AK 99577 Current property owner(s) JAMES & SANDRA JOBKAR Mailing address Real estate agent Day phone 19639 SECOND STREET, EAGLE RIVER, AK 99577 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 - 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 550 Date of Payment 0 7 (J,� Receipt Number 717210 COSA# 030115 22 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY ANCHORAGE AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 8/26/2021 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to OF A these various and dynamic characteristics and are outside the control of the evaluator of the �' •�• `•"9 well and septic system. Therefore, any estimate of how long a system will function satisfactory ��Q: • • • • . for current or future occupants or guarantee that no unseen encroachments, deficiencies or "oe q - discrepancies exist can be given by First Water Consulting &: � �• Fc � . .. ....... .... 6. DSD SIGNATURE • • • • • �'" • Curtis Huffman ;101 System #1 Approved for 3 bedrooms �29�s•. CE 128991 .$/26/Z1 •'�� System #2 Approved for bedrooms ��PR ESSO .� Disapproved Conditional approval for bedrooms, with the following stipulations: OBy: Original Certificate Date: / /%4p e,? / The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist Legal Description: COLONIAL PARK B2, L9 Parcel ID: 050-302-09 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 7/1981 Total depth 332 ft Cased to 40+ ft (PER MOA DOCS) Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 8/5/2021 Static water level at beginning of test 290 ft. Well production at time of test 5 gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 2.24 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample 8/5/2021 Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) NA – NEW TANK years Tank type/material SEPTIC / HDPE Measured operating fluid level in septic tank NA Standpipes/foundation cleanout per record drawing Date of pumping NA C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 8/20/1982 ALL standpipes present per record drawing Total measured depth from grade 11.9 ft (max) Measured depth to pipe invert from grade *4.5 ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective *7.4’ INTO THE 8’ED Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date 8/5/2021 Results Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 9 in (6” first 50 gallons added…) Elapsed time <15 min Final fluid depth 0 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) N If yes, enter date Comments/Deficiencies: *INVERT & TOTAL DEPTH BASED ON VISUAL TOP OF PERF AT MT. E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10’ Yes if No ft Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No F. ENGINEER’S COMMENTS G. ENGINEER’S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 8/26/21 Received Date/Time 08/06/2021 9:42 08/05/2021 13:05Collected Date/Time 1214920001 Matrix SGS Ref.# Client Sample ID Colonial Park Blk 2 Lt 9 Client Name Project Name/# Printed Date/Time 08/26/2021 8:42First Water Consulting Services (FWCS) Technical Director Stephen C. Ede Colonial Park Blk 2 Lt 9 Drinking Water Sample Remarks: Parameter Results LOQ Units Method Allowable Limits Prep Date Analysis Date InitContainer ID NRZ08/11/21SM21 2540Cmg/LTotal Dissolved Solids 254 10.0 (<500) D Metals by ICP/MS AKA08/13/21SM21 2340Bmg/LHardness as CaCO3 08/12/21ND5.00 B Waters Department EBH08/09/21SM21 4500NO3-Fmg/LTotal Nitrate/Nitrite-N 2.24 0.200 (<10) C Microbiology Laboratory M.A08/06/21SM21 9223B100mLE. Coli Negative 1 A M.A08/06/21SM21 9223B100mLTotal Coliform Negative 1 A Private Individual Analysis A.A08/24/21EPA 300.0mg/LChloride 08/23/2114.1 0.200 (<250) D SEM08/09/21SM21 2510Bumhos/cmConductivity3985.00 D A.A08/24/21EPA 300.0mg/LFluoride 08/23/21ND0.200 (<2)D A.A08/24/21EPA 300.0mg/LSulfate 08/23/2129.2 1.00 (<250) D SEM08/09/21SM21 2320Bmg/LAlkalinity14410.0 D AKA08/13/21EP200.8ug/LAluminum 08/12/2124.4 20.0 B AKA08/13/21EP200.8ug/LAntimony 08/12/21ND1.00 (<6)B AKA08/13/21EP200.8ug/LArsenic 08/12/21ND5.00 (<10)B AKA08/13/21EP200.8ug/LBarium 08/12/21ND3.00 (<2000)B AKA08/13/21EP200.8ug/LCadmium 08/12/21ND0.500 (<5)B AKA08/13/21EP200.8ug/LCalcium 08/12/21ND500B AKA08/13/21EP200.8ug/LChromium 08/12/21ND5.00 (<100)B SEM08/09/21SM21 2320Bmg/LCO3 Alkalinity ND 10.0 D Page 2 of 6 Received Date/Time 08/06/2021 9:42 08/05/2021 13:05Collected Date/Time 1214920001 Matrix SGS Ref.# Client Sample ID Colonial Park Blk 2 Lt 9 Client Name Project Name/# Printed Date/Time 08/26/2021 8:42First Water Consulting Services (FWCS) Technical Director Stephen C. Ede Colonial Park Blk 2 Lt 9 Drinking Water Parameter Results LOQ Units Method Allowable Limits Prep Date Analysis Date InitContainer ID Private Individual Analysis AKA08/13/21EP200.8ug/LCopper 08/12/215.31 1.00 (<1000) B SEM08/09/21SM21 2320Bmg/LHCO3 Alkalinity 140 10.0 D AKA08/13/21EP200.8ug/LIron 08/12/21ND250(<300)B AKA08/13/21EP200.8ug/LLead 08/12/213.44 0.200 (<15) B AKA08/13/21EP200.8ug/LMagnesium 08/12/21ND50.0 B AKA08/13/21EP200.8ug/LManganese 08/12/211.13 1.00 (<50) B AKA08/13/21EP200.8ug/LNickel 08/12/21ND2.00 (<100)B SEM08/09/21SM21 2320Bmg/LOH Alkalinity ND 10.0 D SEM08/09/21SM21 4500-H BpH unitspH8.4 0.100 (6.5-8.5) D AKA08/13/21EP200.8ug/LPotassium 08/12/21606500B AKA08/13/21EP200.8ug/LSelenium 08/12/21ND5.00 (<50)B AKA08/13/21EP200.8ug/LSilver 08/12/21ND1.00 (<100)B AKA08/13/21EP200.8ug/LSodium 08/12/2192700500B AKA08/13/21EP200.8ug/LThallium 08/12/21ND1.00 (<2)B AKA08/13/21EP200.8ug/LZinc 08/12/2116.8 10.0 (<5000) B Page 3 of 6 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 MUNICIPALITY OF ANCHORAGE NViiL~ONMENI'AL SERVICES OlVlSlOh JUL 1 4 1997 RECEIVED CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~ - "L~-,~_..~ .~"~ 1. GENERAL INFORMATION Complete legal description Lot 9; Block 2; Colonial Park ? L~cation (~ite,add[~ess or directions) ....... Prt~perty owner ....Duane & -Mailing address P.,o. Box Lending agency 19639 Second Street Eaqle River, AK Karen Myers 77043~ Eagle River, Day phone AK 99577 Day phone 263-0700 Mailing address Agent Cindy Wilson/ Partners Real Estate ' Day phone 244-1930 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: 3 Individual well xxx Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my inves_ti_,qation and inspection, the on-site water ~upply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. s & s ENmHEERIHC~ Phone ~/~ ~- ~'~ 7 ~ Name of Firm ........ ,- -, .... , ...... -' -- ~' Eagle R~er, Alaska 9~5~ Address Engine,s signature .~~~ ~' Date 7 //~/~7 6. DHHS SIGNATURE ~,,~Approvedfor' ~'~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Rev. 1/91) i~K:K MOA#21 Legal Description: A. WELL DATA ~UNIOP~W OF ,~..HO~ Municipality of Anchorage m I. SERVICES ~ DEPARTMENT OF HEALTH & HUMAN SERVIC~mN~E~A Environmental Services Division JUL 1 4 1997~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 RECEIVED Health Authority Approval Checklist Well type /~,~vA?~ Log present ~1) ,c/'~ Total depth ~_~ Z. Sanitary seal ~1) Date of test Static water level If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to z~) I~ FROM WELL LOG -. Nitrate Well production - /,() , ~ ~ ~ . ; ~ . ~ . WATER SAMPLE RESULTS: Coliform Date of sample: SEPTIC/HOLDING TANK DATA Casing height (above ground) Wires properly protected AT INSPECTION g.p.m. , ~.;~z~. ~3 $ & $ ENGINEERING Collected by: 17~ ~e Ri~er, Alaska 99577 Date installed ~ Tank size Foundation cleanout (_,Y.~ Date of ~J~nNUmber of Compartments ~ Cleanout~N)~ Depressio (Y~) ./J_/'~ High water alarm (Y/N)~,~.~ Pumper ~ ABSORpTiON FIELD DATA Datein'stalied'., . ~//~/~7--, ';rSoilrating (g.p.d./ff'orff~/bdrm)/~ ~System~pe ~C~ Length'~ ~/ Width ~ # Gravel thickness below pipe ~ / Total depth /~ / ~' ' ~ present~)~ Depression over field (Y~ ~ Effective absorption area ~ ~' Monitoring Tube Date of adequacy test ~~ Results ~ail)~ For ~~ Fluid depth in absorption field before test (in.); ~ ~// Immediately affer~ gal. water added (in.): Fluid depth ~ II (ins) Minutes later: ~;~ Absorption rate = ~ ~ g.p.d. per°~d~ treatment (past 12 months) (WN) AJf~ ~/ If yes, give date bedrooms 74" 72-026 (Rev. 3/96)* LIFT i~iiehilii:C~ealSm (l~/v~)lS t a I I e d ~_t* -'"'"'~~_. Dat u m S ~z e ~,~~alIens Cycles tested SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /./'),.~ ' '/- Absorption field on lot /~0 / '/' Public sewer main Sewer/septic service line ,.~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation lO/~r Property line tOj4' Absorption field Water main/service line ,_~' 'f' Surface water/drainage ./L'~ ~'~ "Pump off" level at* On adjacent lots /CF/_-) On adjacent lots /_/~ Public sewer manhole/cleanout Lift station ,~///,~ Wells on adjacent lots ,/c-~/-/- SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Building foundation /'~)/-/' Water main/service line Driveway, parking/vehicle storage area Property line /O/-/' Surface water //9t3_ / ~ Curtain drain ~/,~. ENGINEER'S CERTIFICATION Wells on adjacent lots I certify that~1 have determined thru field inspections and review of Municipal re~ms are -.~ -in c°nf°rmance--~2h M-~12AA, g~ine_s in effect on this date. ~innature ~ .-- ~ ~ ~~ Engineer's Name ~o~-~r c. Co~ Date ~ t ~ ~ CE-8801 . .. HAA Fee $ Date of Payment Receipt Number__ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 07/28/1997 18:47 9076941211 S AND S ENGINEERING 3UL-14-199~ 15:52 CT&E E~i J:lHC~ PAGE 03 IlL il.._ ~i~ Na~ '*'lbnt bmpl~ ID Etbded Date/Tim 07114197 12:32 Colleded D~e/Time 07100197 I 5:1 $ Received hit/Time 0711019'7 09:00 Te~icM Diredor~, ~ C, Ede Nftrete-N % 0.~ 0.1~ qlL ~15 4~0-~ 10 m 01110197 JBL T~mT ~Jfo~ S ~ v/o outi ~18 ~l ." O~[IO/B~ T~ '--, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) LegalC:~ ¢ Description (include lot, ~"~'~ ~ block, subdivision, se.,~ion, ?wnship, range)...~-~%~~~'~~ ~ ' ~'"' Location (address or directions) (b) Applicant Name/("/~//.~.~t.. ~ Telephone: Home ~ ~¢~ .~' ~ Business ~'~ ..~- ~/~0 Applicant Address ~' .~ ~ ~ ~/ ~~ ~~~ ~~ ~ (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lending Institution "~~ "~v~4")~.~---~'~..~ Telephone Address (e) Real Estate Company and Agent Address ,/..jT~elephone (f) H~if-the HAA to the following address: TYPE OF RESIDENCE Single-Family,S' Multi-Family [] Number of Bedrooms J Other WATER SUPPLY Individual Well~ Community [] Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. E.NGINEERING FIRM PROVIDING~I'NSPECTIONS, TESTS, FILE SEARCH, DAT"~ AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Telephone DHEP APPRO. ~. . Approved for L/'c~ L.v--~.__~bedrooms c~--~._z~...~te Approved ~ Disapprovec~ Conditional'/' ~ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 {11/84} WELL DATA MUNICIPALITY OF ANCHORAGE (MOA~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: /-~ ~ Well Classification ~'~'~- [ ~/~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Completed Yield MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MAR 2, 6 R CEiVED Total Depth ,~'~Z''` Cased to Static Water Level ~'~,C~" Casing Height Above Ground Electrical Wiring in. Conduit Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on J_ot To Nearest Public Sewer Line Cleadout/Manhole Depth of Grouting Pump Set At L.x,~ Sanitary Seal on Casing ~/1~ Depression Around Wellhead ~/~ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed (~::)-Z~- c~'-Z-- Size \ c)~ No. of Compartments 'Z- Standpipes ~/N')". Air-tight Caps (~/J,~r) Foundation Cleanout (Y.'~ Depression over Tank.(-Y~ Date Last Pumped ~- ~l ~ ~ /'J/,~*"'- ' for ~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~,C:)~ To Property Line Z.~.~ ' To Water-Mere/Service Line '~C>~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field Course To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~'" Width of Field Square Feet of Absorption Area Depression over Field,(,Y~ Results of Last Adequacy Test Type of System Design "~~ Length of Field ~c~ ~ Depth of Field ~ 'Z'l Gravel Bed Thickness ~ ~ Standpipes Present G/J~ Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ! To Building Foundation ~. ~ ' Lot To Water M&ir,/Service Line ~'~ ~" ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line /O I C- To Existing or Abandoned System on · On Adjoining Lots '~5 ~ ~' To Cutbank (if prese.nt) Comments LIFT STATION Date Installed Size in Gallons High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ~ ~ _~-..,~' '--"""~ SRB 196x Company ~agle River, Jla~ca ~ Receipt No. ~ ~ Date of Payment ~'~-~ Amount: $ ~ ~ Page 2 of 2 72-026 (11/'84) APPLI ' NT FILLS OUT UPPER HA[ ONLY Property Owrmr //~,~ /~. ~-- r~ , ~n e' v"' Phone MailingAddre~ ~. ~0~ ~] ~ /~ ~,~;'~ ZipC°de~7 ~~ Buyer ~,~ ' ~ ' Address Zip Code Lending Institution Phone Address Zip Code RealtyCo.&A~nt ~7~, ~.~/, ~r Phone Address Zip ~e Legal Descript~n' ~O ~ ~ ~/Z ~ ~Ye ~ ,~ ~ ~' ~ ~ Street Locati~ ~ ~ ~. ~/C[ q~ ~ Type of Resi~nce ~Single Family ~ Multiple Family No. of Bedroo~ ~ ~ Other Water Supply ~ /~ ~ p~ ~, A~ACH ~LL LOG. A w~l log is r~uir~ for all wells drl~ed since June 1975. ~lndivid~l ~ Community'~ For wells ~illed prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal ~ ~.d,v~ ~ea. ~d~v~ua~ ~.~,.~: ~ 9~ ~ Public ~ility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspeclor Inspector Nt[ ~NICIPALiT; ......... Field Notes: [""* ~T RECEI_V_ED ( ~/'~APPBOVED BEDF:IOOM8 'CONDITION8 OF APPROVAL ( ) DISAPI~IOVED ( ) CONDITIONAL APPR VO_.~.L' Date ,"'~- ~ "' '~ Soils Rating Date Sewer Installed Well To Absorption Area ,/'~.--.~2/ Well Log Received ~ /~' / ~ ~j ~. .,.: '~' We, to Tank // O ' Septic Ta, k Size 72-023(3/82)